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Ugliono et al. Mini-invasive Surg 2021;5:2 I http://dx.doi.org/10.20517/2574-1225.2020.93 Page 7 of 12

To date, there is no high-level objective evidence recommending the use of meshes in PEH surgical
treatment, nor demonstrating the superiority of a specific technique over another. The ideal mesh does not
exist, and the choice of the technique largely depends on the surgeon’s preferences [50,51] . Current guidelines
[5]
admit that no recommendations can be made regarding the use of mesh in PEH repair .
“Short esophagus” and esophageal lengthening
The entity of the “short esophagus” (SE) is debated. SE is defined as less than 2-2.5 cm of intra-abdominal
[52]
esophageal length after extensive mediastinal dissection . The estimated incidence of the SE is reported
[4]
to be 1.9%-20% and is thought to be caused by fibrosis and scarring of chronic severe GER insult .
Some authors question the real existence of SE, claiming the presence of “apparent” SE: a normal-length
[53]
esophagus that is folded into the chest and appears to be short before extensive mediastinal mobilization .
The use of routine intraoperative endoscopy during PEH repair is suggested to detect SE .
[54]
When a “real” SE is recognized intraoperatively, esophageal lengthening procedures, such as Collis-Nissen
[55]
fundoplication, are indicated . The current technique consists of a totally laparoscopic gastroplasty,
performed with a circular stapler, to create a trans-gastric window, through which a linear stapler is
[56]
introduced to create the “neo-esophagus” . The results of this procedure, performed with the laparoscopic
approach, are similar to those reported with the open technique, with a recurrence rate of 25-13% .
[4]
However, Collis-Nissen fundoplication is a challenging procedure, with a reported morbidity rate of 19%-
[57]
36%, including atelectasis, pneumonia, pneumothorax, and pleural effusion . Moreover, it carries a higher
[58]
risk of leak compared to fundoplication alone (2.7% vs. 0.6%) .
Anterior gastropexy
Anterior gastropexy was first described by Boerema in 1969, but it was abandoned due to a reported
excessively high risk of recurrence, which occurred in 60% of patients [59,60] . With the recognition of the
importance of the fundamental technical steps of the procedure, such as sac dissection and excision, that
were not performed at the time of the original Boerema procedure, this technique has been modified and
proposed again. To date, there are limited data regarding the role of anterior gastropexy, in particular
without associated procedures such as mesh cruroplasty or fundoplication, in PEH surgical treatment [Table 1].
[68]
Only Daigle et al. performed a multicenter study of 101 PEH repair with anterior gastropexy without
fundoplication, showing an acceptable recurrence rate of 16.8% at 12-month follow-up and avoiding
complications of mesh positioning and anti-reflux procedures. However, 29.7% of patients experienced
some degree of postoperative GER.

More recently, several authors have described the use of this procedure in the acute setting or in high-risk
patients [68,70] . In these situations, the procedure was considered attractive because it does not require long
operative times or advanced technical skills even with the minimally invasive approach, and does not affect
the possibility to perform subsequent elective PEH repair.

[69]
For instance, Yates et al. reported the results of 11 high operative risk patients presented with acute
gastric volvulus and treated with laparoscopic anterior gastropexy. There were no intraoperative
complications, but two patients required reintervention. The authors concluded that laparoscopic anterior
gastropexy could be considered a valid surgical alternative for frail patients.

Gastroesophageal reflux
The systematic or tailored addition of a fundoplication during PEH repair is a matter of debate.